It takes great medical minds to create powerful solutions that solve some of healthcare’s most complex challenges. Join us and put your expertise to work in ways you never imagined possible. We know you’ve honed your career in a fast-moving medical environment. While Gainwell operates with a sense of urgency, you’ll have the opportunity to work more flexible hours. And working at Gainwell carries its rewards. You’ll have an incredible opportunity to grow your career in a company that values work-life balance, continuous learning, and career development.

Summary

We are seeking a talented individual for a Nurse Reviewer (RN) who will be responsible for performing clinical reviews to determine if the medical record documentation supports the need for the service based on clinical criteria, coverage policies, and utilization and practice guidelines as defined by review methodologies specific to the contract for which services are being provided. This involves accessing proprietary systems to audit medical records, accurately documenting findings and providing policy/regulatory support for determination. This position is intended for pipelining. We will accept applications on an ongoing basis.

Your role in our mission

• Reviews and interprets medical records and compares against criteria to determine appropriateness and reasonableness of care; apply critical thinking and decision making skills to determine if the medical record documentation supports the need for service while maintaining production goals and quality standards.
• Document decisions and rationale to justify review findings or no findings.
• Determines approval or initiates a referral to the physician consultant and processes physician consultant decisions ensuring reason for the denial is described in sufficient detail and completed within contractual deadline.
• Performs prior authorization, precertification, and retrospective reviews and prepares decision letters as needed in support of the utilization review contract
• Assists management with training new Nurse Reviewers to include daily monitoring, mentoring, feedback and education.
• Maintains current knowledge of clinical criteria guidelines and successfully completes required CEUs to maintain RN license
• Responsible for attending training and scheduled meetings to enhance skills and working knowledge of clinical policies, procedures, rules, and regulations.
• Actively cross-trains to perform reviews of multiple claim types to provide a flexible workforce to meet client needs.
• Recommends, tests and implements process improvements, new audit concepts, and technology improvements that will enhance production, quality, and client satisfaction

What we're looking for

• Demonstrated proficiency in computer skills, and typing, i.e., Microsoft Windows, Outlook, Excel, Word, PowerPoint, Internet browsers, etc.
• Active, unrestricted RN licensure from the United States and in the state of primary home residency, active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact (NLC), required; this will be verified during a post-offer background check
• 5+ years clinical experience in an inpatient hospital setting required
• 2+ years utilization review experience or claims auditing required
• Experience using Milliman or InterQual criteria required
• Ability to work during normal business hours as this position requires frequent interactions with the team and other departments within the company
• May be required to work extended hours for special business needs

What you should expect in this role

• This is a full-time permanent regular salaried (W-2) employee position. This is not a contract or short-term position.
• Health benefits (medical, dental, vision) and paid time off benefits start on day 1 of employment.
• Company provided computer.
• Monday through Friday work schedule.
• Employees in this role will work from home and must be within the continental US when working.
• Work location must be free of distractions, loud noises, recording devices, and private.
• May be required to travel at least 10% of time based on business needs
• For remote (work from home) positions employees' Broadband Internet connections, should have a minimum speed of 24MBS download and 8 MBS upload. Greater speeds will of course provide better performance.
• To Test your internet download and upload speed:
• Go to Google.
• Search for Internet Speed Test.  
• Video cameras on phone, tablet, or computer must be used during all interviews. The camera on the company provided laptop must be on during the initial week of orientation, if hired.
• Please understand that when applying entering all zeros, 12345, all the same number, or "negotiable" will result in your application being discarded.

• Be sure to let us know the exact salary within the posted salary range you desire on your application.